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Hypertensive Disorders of Pregnancy

Megan Jones, MD and Neda Frayha, MD
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There are four main types of hypertensive disorders in pregnancy, and there are nuances to how each should be managed differently. In this segment, Drs. Megan Jones and Neda Frayha walk us through these four categories, how to tell them apart from one another and how to manage them, including when to consider early delivery.

Pearls:

  • The key to hypertensive disorders in pregnancy is getting the appropriate history and knowing the criteria for diagnosis, which impacts management and timing of delivery.

  • The four types of disorders are: chronic hypertension, gestational hypertension, preeclampsia/preeclampsia with severe features and chronic hypertension with superimposed preeclampsia.

 

  • Why is hypertension in pregnancy important?

    • Mom - hypertension is one of the top three causes of mortality in the US. Women with hypertension in pregnancy have increased rates of chronic hypertension, type 2 diabetes and hyperlipidemia for decades after delivering

    • Baby - may lead to intrauterine growth restriction and fetal demise

  • Hypertension in pregnancy = >140/90 on two separate occasions at least 4 hours apart

    • 1. Chronic Hypertension: hypertension prior to 20 weeks gestation

    • 2. Gestational hypertension: hypertension after 20 weeks gestation

    • 3. Preeclampsia: hypertension >140/90 on two separate occasions or >160/110 confirmed over shorter interval AND

      • Proteinuria (300mg in 24 hours) OR

      • One of the following:

        • Thrombocytopenia

        • Impaired renal function

        • Impaired liver function

        • Pulmonary edema

        • Cerebral/visual symptoms

      • Preeclampsia with severe feature: >160/110, symptoms of headache/right upper quadrant pain/vision changes, labs consistent with HELLP syndrome

    • 4. Chronic hypertension with superimposed preeclampsia: challenging to diagnose but important to differentiate because the preeclampsia piece can quickly progress

  • Evaluation for those with chronic hypertension:

    • CBC, BMP, AST/ALT, 24-hour urine protein

    • Repeat labs if you have are concerned they are developing preeclampsia

  • Treatment:

    • For those with chronic hypertension, blood pressure tends to improve in the first 20 weeks of pregnancy.

    • Nifedipine and labetalol are oral agents used and initiated after 34 weeks

    • Goal is keeping people in the 140/90’s but certainly below 160/110

    • See patient monthly to make sure blood pressure is under control

    • Fetal anatomy and growth scans started at 20 weeks every 4-6 weeks to make sure fetus is growing well

    • By 32 weeks and beyond, twice weekly antenatal testing (nonstress test or biophysical profile) weekly. May do earlier if they have significant hypertension. Also weekly labs.

  • Delivery Management:

    • Chronic hypertension: 38-40 weeks depending on the guidelines and how well-controlled

    • Gestionational hypertension and preeclampsia: 37 weeks to avoid stillbirth

    • Preeclampsia with severe features: monitoring in hospital, blood pressure control and delivery at 34 weeks if possible.

 

Reference:

ACOG Practice Bulletin 33: Diagnosis/ Management Preeclampsia and Eclampsia [January 2002]

ACOG Practice Bulletin 125: Chronic HTN in Pregnancy [July 2001]

Obstetric Intensive Care Manual: 3rd edition. Foley, MR, T Strong, T Garite. 2011.

Management of hypertension in pregnant and postpartum women. P August. UpToDate.com. 2012.

Hypertension in Pregnancy. ACOG, SMFM, AAFP. Task Force. 2013.

Stuart JJ, Tanz LJ, Missmer SA, et al. Hypertensive disorders of pregnancy and maternal cardiovascular disease risk factor development. Ann Intern Med 2018; 169:224-232. doi:10.7326/M17-2740.

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Clots and OCP's Full episode audio for MD edition 177:43 min - 83 MB - M4APrimary Care RAP December 2018 Written Summary 502 KB - PDF

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